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SAN JOAQUIWOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ]r; FACILITY ID# SERVICE REQUEST# <br /> C-iF oa3fl6 s5<� <br /> OWNER/OPERATOR <br /> IVa --cr„� S <br /> CHECK If BILLING ADDRES <br /> FACILITY NAME C�i Lts V:60y� <br /> SITE ADDRESSl Li /'P L'-4&N,A 5-F ES G/ U <br /> f LN nryS',3 w <br /> Street Number Direction city <br /> Street Nam¢ ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (2e,9) <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Carl W Henderson <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME HMC- Henderson Maint CO PHONE If EXT. <br /> (209)467-7573 <br /> HOME or MAILING ADDRESS p0 Box 31325 - Stockton, CA 95213 FAx# <br /> 1209 ) 465-4988 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. Q <br /> APPLICANT'S SIGNATURE: (241.x( ti- DAVE:: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT MSF L.�'+AX12AC�0� <br /> IrAPPL/CANT IS not the BILL/NG PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: REC T <br /> COMMENTS: DLp(hCCN- I��f SEL UDL �IUA-� . <br /> JUL 1 8 2008 <br /> SAN RONIN COUNTY <br /> HEALTH DE ART j NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: AlAloy EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: c-%>2?40. <br /> UO Amount Paid Z`fL4 Payment Date <br /> Jp �118'IvY <br /> Payment Type ✓ Invoice# Check# -I 3g Received By: <br /> EHD 48-02-025 S <br /> REVISED 11117/2003 R FORM(Golden Rod) <br />